Work environments such as, for example, process control, nuclear power, health care, military, and manufacturing generally lack a shared understanding of systemic failures and causes related to incidents. An “incident” in these examples may be an “actual loss” event that may be investigated so that effective action can be taken to prevent the same or similar losses from again occurring. A “near miss” event can also be considered an “incident”. In this case, no actual loss may have occurred, but the potential for a loss may have been present. A “near miss” may be considered an occurrence in which “actual loss” (e.g., property damage, environmental impact, or human loss) or an operational interruption could have plausibly resulted if circumstances had been slightly different. Such events can thus be considered “incidents,” “process upsets,” or “system upsets”, wherein such a “system” includes human components and machine portions in a work environment.
Incidents may result from the failure of field devices such as, for example, instrumentation, control valves, and pumps or from some form of process disturbance that causes operations to deviate from a normal operating state. Incidents also occur due to human factor and related failures such as human error or problems with current management systems (e.g., training, work processes, procedures, communications, supervision, etc). Early detection of such failures, whether they are operations practice failures, equipment failures, or management systems problems enables an operation team to improve current practices to prevent incidents from occurring in the future or supporting more effective response when problems occur. Continuous learning from incidents and understanding systemic failures is a key to developing effective corrective actions with long-term benefit.
Based on the foregoing, it is believed that a need exists for an improved method and system for effectively identifying a systemic failure and a root cause of incidents. In particular, a need exists for understanding failures and root causes at two basic levels: (1) for a single incident; and (2) more importantly, across incidents. It is believed that analyzing across incidents is a crucial factor to identifying systemic failures and root causes. Otherwise, one will constantly be fixing problems isolated to individual incidents and the likelihood of successful corrective actions with desired long-term and far reading effects will be much lower.